APP

2 Weeks: Burch Colposuspension

Common Concerns

• Similar to RMUS

Actual Complications

• Continued SUI
• Urinary retention

2 Weeks: Burch Colposuspension

Common Concerns

• Similar to RMUS

Actual Complications

• Continued SUI  subsequent surgery, ensure no UTI
• Urinary retention  ticture of time, suture release/urethrolysis

2 Weeks: Anal Sphincteroplasty

Common Concerns

• Bowel management
• Pain

Complications

• Continued fecal incontinence
• Wound infection
• Wound dehiscence

231

2 Weeks: Anal Sphincteroplasty

Common Concerns

• Bowel management  constipation versus diarrhea

Complications

• Continued fecal incontinence  review bowel regiment, immodium, ensure 
no C. diff

• Wound infection  debridement, antibiotics, perineal care
• Wound dehiscence  packing, surgical revision

2 Weeks: Sacroneural Modulation

Common Concerns

• Incision 
• How do I work this thing?

Complications

• Incision infection 
• Continued incontinence

2 Weeks: Sacroneural Modulation

Common Concerns

• Incision 
• How do I work this thing?

Complications

• Incision infection  antibiotics, wound care
• Continued incontinence  change program, change intensity

232

Three Months Post‐op 
Visit

3 Months: RMUS Complications

• Recurrent UTIs since surgery
• Urgency urinary incontinence
• Vaginal mesh exposure

3 Months: RMUS 
Treatments

• Recurrent UTIs since surgery cystoscopy, vaginal 
estrogen, methanemine/Vit C, antibiotic prophylaxis

• Urgency urinary incontinence  cystoscopy, vaginal 
estrogen, anticholinergics, PFPT, intravesical botox, SNS

• Vaginal mesh exposure  vaginal estrogen, operative 
intervention

233

3 Months: Vaginal Hysterectomy w/Ligament 
Suspension Complications

• Recurrent prolapse
• Exposed suture
• Granulation tissue
• Pain with intercourse

3 Months: Vaginal Hysterectomy w/Ligament 
Suspension Treatments

• Recurrent prolapse  observe, pessary, repeat surgery
• Exposed suture  excision
• Granulation tissue  silver nitrate cauterization, 

operative intervention
• Pain with intercourse  physical therapy, vaginal dilators, 

sex counselor

3 Months: Hysterectomy w/Sacrocolpopexy

Laparoscopic or Robotic

Complications

• Mesh exposure
• Bothersome vaginal discharge
• Recurrent prolapse
• Discitis

234

3 Months: Hysterectomy w/Sacrocolpopexy

Laparoscopic or Robotic

Treatments

• Mesh exposure  observe, vaginal estrogen, operative intervention
• Bothersome vaginal discharge  exam, rx for BV
• Recurrent prolapse  pessary, surgical reoperation
• Discitis  MRI, ortho/spine consultation, IV antibiotics, operation

3 Months: Colpocleisis

Complications

• Recurrent prolapse  small pessary, surgical intervention

3 Months: Anal Sphincteroplasty

• Fecal incontinence  physical therapy, vaginal insert, SNS

235

One Year Post‐op Visit

1 Year: RMUS
Complications

• Recurrent UTIs since surgery

• Two in six months or three in one year

• Vaginal mesh exposure

1 Year: RMUS
Treatments

• Recurrent UTIs since surgery  cystoscopy, vaginal 
estrogen, suppressive therapy

• Vaginal mesh exposure  operative excision

236

1 Year: Vaginal Hysterectomy w/Ligament 
Suspension

Complications

• Recurrent prolapse 
• Exposed suture
• Granulation tissue 
• Dyspareunia

1 Year: Vaginal Hysterectomy w/Ligament 
Suspension

Treatments

• Recurrent prolapse  pessary, surgical correction
• Exposed suture  excision
• Granulation tissue  silver nitrate, excision
• Dysparunia  physical therapy

1 Year: Hysterectomy w/Sacrocolpopexy

Laparoscopic or Robotic

Complications

• Mesh exposure
• Recurrent prolapse
• “My autoimmune diseases are caused by the 
mesh!!”

237

1 Year: Hysterectomy w/Sacrocolpopexy

Laparoscopic or Robotic

Treatments

• Mesh exposure  operative excision
• Recurrent prolapse  pessary, surgical correction
• “My autoimmune diseases are caused by the mesh!” 

NO EVIDENCE and ITS ACTUALLY BEEN LOOKED AT!

1 Year: Colpocleisis

Complications

• Recurrent prolapse  pessary, surgical correction

1 Year: Anal Sphincteroplasty

Complications

• Fecal incontinence  physical therapy, Eclipse 
device, sacroneuromodulation

238

Key Points

• Most patients report fatigue and pain at the two weeks post‐op visit

• These symptoms are common and not surprising
• Reassure them!

• Most common complications are UTI and urinary retention
• Most short term post‐op complications, including severe 

complications, are identified at or before the 2‐week post‐op visit
• Permanent mesh and suture complications can take longer to develop

239

Notes

Evaluation and Management of
Anterior Vaginal Wall Masses

Brian J. Linder, MD, MS

@brianjlinder

Assistant Professor of OB/Gyn
Assistant Professor of Urology

Mayo Clinic, Rochester, MN

Disclosures

• None

Objectives

• State the differential diagnosis of an anterior vaginal wall mass
• Describe the role for additional testing when evaluating an

anterior vaginal wall mass
• Discuss treatment options for anterior vaginal wall masses

240

Anterior Vaginal Wall Mass- Differential

“DBUG SPCE”
•Diverticulum
•Bulking agent

•(Bartholins should be posterior vaginal wall, 5 or 7 o’clock)
•Ureter (ectopic, ureterocele)
•Gartner duct cyst
•Skene’s gland
•Prolapse (Urethral or Anterior vaginal wall)
•Cancer, Caruncle
•Epidermoid cyst

©2012 MFMER | slide-4

Anterior Vaginal Wall Mass- Evaluation

• History
• Physical
• +/- Imaging

• MRI is the modality of choice
• CT scan and US are options

• +/- cystoscopy

Urethral Prolapse

• Circumferential lesion
• Beefy red
• Donut
• Bleeding/spotting
• Imaging- None
• Tx: Observation, topical estrogen, sitz

baths, excision

241

Urethral Caruncle

• Distal urethra or meatus
• Reddish exophytic lesion
• Imaging- None

• Tx: Observation vsTopical estrogen
vs Excision

Urethral Diverticulum- Epidemiology

• Incidence < 0.02% 1
• Rochester Epidemiology Project,1980-2011
• Annual incidence 18/1 million

• Risk factors 2

• African American descent

• Chronic infection

• Gonoccocal, but most culture out e.coli in urine

• Trauma

• Periurethral injections 1 El-Nashar SA et al, Int Urogyn J, 2014
2 Crencenze IM et al, Curr Urol Rep, 2015

Pathophysiology

• Periurethral
glands

- Obstructed

- Infected

- Dilated
- Eventually

ruptures into the
urethral lumen

Rovner E, Campbell’s, 11th ed

242

Clinical Presentation

• Presenting symptoms: 3 D’s
• Dysuria, Dyspareunia, post-void Dribbling
• Contemporary series- only 5% 1
• 27% had none of these

• Most common presentations- recurrent UTI,
dyspareunia, vaginal mass, SUI 1

1 Baradaran N et al, Urology, 2016

Clinical Exam

• +/- expression of fluid per urethra

Diverticulum Work-Up

• Pelvic MRI (imaging of choice)

• Dark on T1, bright on T2

• Cystoscopy (irritative sx, microhematuria, etc.)

• Ostia- Posterolaterally in mid urethra
• Stone, bladder malignancy, etc.

• Possibly UDS

243

MRI- Diverticulum

Axial T2 series

Distinguish from other lesions, location, number/septations, size,

configuration, communication Leach GE, Neurourol Urodyn, 1993

MRI- Diverticulum w/ Stone

Axial T2 series

CT Pelvis

Axial, w/ IV contrast

244

Cystoscopy

• Evaluate for discharge with palpation
• Ostia

Management

• Observation (?)
• Marsupialization (Spence procedure)

• Distal lesion, poor surgical candidate

• Endoscopic unroofing, fulguration, coagulation

• Excision with reconstruction (transvaginal)
• Complete resection
• Careful tissue handling
• Tension-free, water-tight closure
• Avoiding overlapping suture lines

Urethral Diverticulectomy

245

Urethral Diverticulectomy

Lee R, Atlas of Gyn Surgery. 1992

Urethral Diverticulectomy

Lee R, Atlas of Gyn Surgery. 1992

Urethral Diverticulectomy

Lee R, Atlas of Gyn Surgery. 1992

246

Urethral Diverticulectomy

Lee R, Atlas of Gyn Surgery. 1992

Urethral Diverticulectomy

Lee R, Atlas of Gyn Surgery. 1992

Other Considerations

• Flap/Graft
• Tissue quality is poor, chronic infection,
reoperation, immunosuppression

• Concomitant anti-incontinence procedure
• Autologous pubovaginal sling
• SUI preop, >3 cm, proximal location 1
• Can be staged approach as well
• 62% of pts with SUI and UD, SUI resolved 2
• Do not use mesh if: urethrovaginal fistula, urethral
erosion, intraoperative urethral injury, urethral
diverticulum 3

1 Stav K et al, J Urol, 2008
2 Reeves FA et al, Eur Urol, 2014
3 Kobashi K et al, J Urol, 2017

247

Pubovaginal Sling

Post Op Management

• 10% pathologic abnormalities 1
• Most common- Adenocarcinoma, then UC, SCC

• Periurethral gland origin

• Urethral foley +/- SP tube to drainage x ~2 wks
• Anticholinergics
• No consensus on antibiotic prophylaxis

1 Crescenze IM et al, Curr Urol Rep, 2015

Diverticulectomy Outcomes

• Success for transvaginal diverticulectomy ~90%1

Complications

• De novo SUI
• Recurrent diverticulum- up to 10%
• Urethral stricture
• Urethrovaginal fistula

1 Crescenze IM et al, Curr Urol Rep, 2015

248

Other Anterior Vaginal Wall
Masses

Skene’s Gland Cyst

• Distal urethra
• Distorts meatus
• No connection with

urethra
• Tx: Marsupialization,

Aspiration,
Excision

Gartner’s Duct Cyst

• Wolffian (mesonephric)
remnant in females

• Anterolateral vaginal wall
• May be associated with

ectopic ureter/duplication,
• Imaging: Including upper

urinary tract
• Tx: Observation vs excision

249

Gartner’s Duct Cyst

Pseudoabscess

• s/p Urethral bulking
• May present with irritative LUTs, obstruction
• Sterile on culture
• Tx: I+D, marsupialization, endoscopic, aspiration

Vaginal Wall Leiomyoma

• Firm round rubbery mass, mobile
• May be asymptomatic
• Muscle-like on MRI
• Tx: Observation vs

Excision/enucleation

250

Urethral Melanoma

• High local recurrence rate, 3yr OS 27% 1

1 Dimarco D et al, J Urol 2004

Summary

AUA Core Curriculum, 2017

Conclusions

• Many anterior vaginal wall masses may be
asymptomatic and can be managed with
observation or conservative measures
(estrogen, etc.)

• Physical exam is key, in some cases other
testing (imaging, MRI preferred) is helpful

• Most lesions are benign, but malignancies can
occur and should be considered with more
severe, refractory, or atypical
presentations

251

Thank you

Email: [email protected]
@brianjlinder

252

Notes

Creating a Peripartum Perineal Clinic

Christina Lewicky‐Gaupp, MD

Associate Professor
Director, Resident Surgical Skills Curriculum
Medical Director, PEAPOD Perineal CLINIC
Department of Obstetrics and Gynecology
Division of Female Pelvic Medicine & Reconstructive 
Surgery Northwestern University Feinberg School of 

Medicine

Why do We Care about Maternal Birth 
Trauma?

• OASIS

• Wound breakdown: 25% 1
• Wound infection: 20% 1
• Rectovaginal fistulas: 9% are related to obstetric trauma 2
• Anal incontinence postpartum

1. Lewicky‐Gaupp C et al. Obstet Gynecol 2015 May;125(5):1088‐93 
2. Brown HW et al.. Int Urogynecol J 2012 Apr;23(4):403‐10.

253

Anal Incontinence after OASIS

Author Year N Follow‐up AI FI

Lewicky‐Gaupp 2016 178 3 months 59% 15%
25% 9%
Richter 2015 442 6 months 30%
54% 4%
Fenner 2003 165 9 months 31%
59% 28%
Pollack 2004 242 5 years

DeLeeuw 2001 125 14 years

Nygaard 1997 29 30 years

Anal Incontinence after Birth

PRENTICE WOMEN’S HOSPITAL: 2014 UNITED STATES: 2013

• Live births: 12,128 • Live births: 3,932,181
• Vaginal births: 8,919 • Vaginal births: 2,642,892
• Disruption of sphincters (3.7%): 327 • Disruption of sphincters (5%): 32,144
• Incontinence as a sequelae (25%): 82 • Incontinence as a sequelae (25%): 33,03

2 new cases every week One new case every 14 minutes

NW EDW data 2013  CDC 2013 

Why PEAPOD?

254

Why PEAPOD?

These women at 
increased Risk of…

• Pain
• UI
• FI
• Wound 

complications 

What Can We do Better? 
In the Delivery Room …

On the Ski Slopes

255

What Can We do Better? 
In the Delivery Room …

“All I know is that everyone was looking at my bottom 
and shaking their heads, I knew it was something bad.”

The Michigan Model: TRANSDISCIPLINARY

The Northwestern Model: 

Peripartum Evaluation and Assessment of Pelvic FlOor
Around the Time of Delivery

256

What Do We Do? 

Case 

• A 32 year‐old G1P1001 female who is status post 
forceps‐assisted vaginal delivery complicated by 4th
degree laceration

• Presents on postpartum day 3 with complaints of 
significant perineal pain and foul‐smelling vaginal 
discharge

Case 

257

What Do We do?

• 1‐2 weeks after delivery

• Wound infection: Augmentin 875/125mg BID, Metronidazole 
500mg BID x 7 days

• Wound breakdown: conservative management versus operative 
reconstruction

• Objective Assessment

• Endoanal US
• 1 quadrant

• Anorectal Manometry
• Squeeze pressure <20mm Hg

• Physical Therapist & Sexual Therapist
• Counseling

Endovaginal Ultrasound

Endovaginal Ultrasound

258

Endoanal Ultrasound

Lots of Counseling

Counseling: Risk of Recurrent OASIS

• Risk of recurrent OASIS
• 5.6% (Baghestan 2011)
• 3.2% (Basham 2012)

• Predictors of recurrent OASIS (Jha 2016)
• Operative delivery

• Forceps (OR 3.12, 95 % CI 2.42–4.01)
• Vacuum (OR 2.44, 95 % CI 1.83–3.25)

• Previous fourth degree tear (OR 1.7, 95 % CI 1.24–2.36)
• Birth weight ≥4 kg (OR 2.29, 95 % CI 2.06–2.54)
• Maternal age ≥35 years (OR 1.16, 95 % CI 1– 1.35).
 Impact of recurrent OASIS on fecal continence  (Sangalli 2000)
• Prior 3rd degree = 2.5%
• Prior 4th degree =26.5%

259

Counseling: FI symptoms

If no fecal incontinence
‐ Next vaginal delivery: low risk of FI

If transient fecal incontinence
‐ Next vaginal delivery: 39% with temporary Fl
‐ Next vaginal delivery: 17‐24% with persistent Fl

If persistent fecal Incontinence
‐ Next vaginal delivery: further functional deterioration

Bek 1992, Faltin 2001, Fynes 1999, Jango 2016

Treatment Options: Physical Therapy 

• “Although birth is only one day in a woman’s life, it will leave an 
imprint on her for the rest of her life.”

‐ Justine Caines, OAM, author of “Birth Journeys”

260

Biology:  Anatomical Changes

• MSK changes during pregnancy (spinal curves change, thoracic spine 
mobility)

• Pelvic Girdle Pain (PS separation, SIJD)
• Joint laxity
• Fractures, Dislocations
• Muscle injury (stretch, avulsions)
• Neural and vascular injuries during delivery (crush injuries, nerve stretch)
• Scarring
• Atrophy

Early Physical Therapy Intervention

• 211 primip women with OASIS
• 109 received PFPT at 6‐8 weeks, 102 started within 30 days
• Early rehabilitation reduced:
‐‐ Gas leakage: OR 0.51 [0.29‐0.90] (p=0.02), 
‐‐ Liquid stool leakage: OR 0.22 [0.08‐0.58] (p=0.02)
‐‐ SUI: OR 0.43 [0.24‐0.77] (p=0.004)

Intervention Modalities: Biofeedback 

261

Intervention: Modalities

• sEMG rectal and vaginal, abdominal, gluteal, upper trapezius
• Rectal balloon catheter re‐training
• Perineal protection

Intervention: Modalities

• Use of dilators, vibrators
• Skin care, lubricants/moisturizers/wipes
• Relaxation /Autonomic Quieting/Graded Exposure
• Self scar mobilization/desensitization
• Resources/Referrals

Counseling: Sex

262

Maureen Sheetz, WHNP, AASECT 
Certified Sexual Counselor

Department of Obstetrics and Gynecology
Division of Female Pelvic Medicine & Reconstructive 
Surgery Northwestern University Feinberg School of 

Medicine

Sex Counselor to the Rescue!

• Women’s health nurse practitioner 
• AASECT certified sexual health counselor
• PLISSIT:

• P = permission to discuss sex ask about it!
• LI = obtains limited information
• SS = offers specific suggestions
• IT = but counselors don’t give intensive therapy 

Female Sexual Function

• Sexual desire
• Arousal
• Orgasm
• Pain
• Sexual symptoms are not considered a dysfunction unless cause they 

cause her  personal distress

33

263

Sex Counseling 

• Pro‐sexuality stance  sexuality is positive, integral 
dimension of being a person

• Encourage couples to expand menu of giving and 
receiving sensual and sexual pleasure

• Assist couples in becoming an intimate sexual team

34

Sexuality

• “When sexuality goes well, it’s a positive integral 
part of a relationship, but not a major component‐
adding about 15‐20% to couple vitality and 
satisfaction.”

• “However, when sexuality is dysfunctional or 
nonexistent, it assumes an incredibly powerful 
role, robbing your relationship of 50‐70% of its 
intimacy and vitality.”
(Metz & McCarthy, 2010)

Sexual Dysfunction

• 90% of women return to “sexual activity” by 12 weeks post delivery 
(Brubaker, et al. 2008)

• But, 60% of women with OASIS delayed resumption of intercourse until 12+ 
weeks PP (Lewicky‐Gaupp et al 2016)
• 94.7% by 1 year (Fodstad et al 2016)

• HOWEVER:

64.3% report sexual
dysfunction in first year 
(Khajehi, et al. 2015)

264

Role of Sex Counseling

• Performs a comprehensive evaluation
• Sex practices, fears, communication, triggers

• Counseling on the difference between “sexual activity” and “vaginal penetrative 
sex”

• When couple avoids touching, sexual comfort and skills atrophy
• Counselor assists with sensate focus exercises

• Normalize the effects of postpartum hormonal milieu
• Prolactin  inhibitory effect on desire 
• Decreased estrogen  vaginal dryness

37

Delivery and Sexual Function

• Decreased sexual desire = most common female sexual disorder
• Sexual function declines with breastfeeding

• Elevated prolactin  lower androgens and estrogen  decreased desire
• Decreased estrogen  worse vaginal lubrication
• Breastfeeding and poor partnership quality  both significant risk factors for sexual dysfunction 
problems postpartum
• Orgasm reduction in 3rd trimester of pregnancy  gradually resumes within 3 months after delivery
• No obstetric variables positively or negatively associated with this outcome
• Most domains of sexual functioning negatively impacted by breastfeeding and low partnership 
quality

Connolly et al (2005), Wallweiner et al (2017)

38

Delivery and Sexual Function

• FINALLY! An article that describes sexual activity as any form of 
sexual contact which may or may not include vaginal sex!

• Sexual activity resumed earlier than vaginal sex

• 53% resuming some form of sexual activity by 6 weeks postpartum 
• 41% attempting vaginal sex

McDonald and Brown (2013)

39

265

What Else Do We Do? 
Research! 

VESPR Study

Vaginal Electrical Stimulation for Postpartum 
Neuromuscular Recovery

P.I. Bhumy Davé, MD
Co‐PI. Christina Lewicky‐Gaupp
Evergreen Invitational Foundation Grant
$103,000

VESPR: Primary Aim

• Compare fecal incontinence (FI) symptoms at 3 months postpartum in 
primiparous women with OASIS who begin immediate vaginal 
electrical stimulation versus sham therapy 

• Randomized controlled trial of patients 
with OASIS

• 1‐2 weeks after delivery
• Electrical Stimulation Device vs. Sham
• 13 week program (10min/day)

266

But…Do New Moms Come to a Perineal Clinic? 

Alexandria Alverdy, B.S., Alix Leader‐Cramer, M.D., Margaret 
G. Mueller, M.D., Kimberly S, Kenton, M.D., M.S., 
Christina  Lewicky‐Gaupp, M.D

Determine the level of patient satisfaction with care at a newly 
developed perineal clinic in a population of women followed 
longitudinally with OASIS 

Presented at AUGS 2016

Methods and Results

 Satisfaction surveys via email
 5‐point Likert scale
 Mostly satisfied (1) to mostly dissatisfied (5)

 31.7% response rate

 Survey received 103 ± 35.1 weeks after last patient visit
 No differences in demographic, delivery, or wound complication data between 

responders and non‐responders

Results

 Patients completely/mostly satisfied with:
 Ability to see a specialist: 95.1% 
 Medical care: 94.1% 
 Follow‐up frequency of visits: 91.8% 
 Emotional support: 89.4% 
 Knowledge gained about postpartum issues: 86.7% 

Satisfaction not different with/without wound complications
Postpartum perineal clinics can enhance national patient satisfaction scores and likely 
improve outcomes!

267

So …Can We Help to Optimize the Birth 
Experience and it’s Outcomes? 

Yes.

What does the Future Hold for Women 
who have Suffered from Birth Trauma?

Key Points

• Maternal birth trauma is not uncommon
• Future directions

• Perineal clinics
• Optimize the treatment of women with birth trauma 

through multidisciplinary approach
• Preventative and recovery research in this population who 

is likely at higher risk for the development of pelvic floor 
disorders

268

Notes

The Intricacies of Bladder
Pain Syndrome

Matthew A. Barker, MD

@MA_BARKER_MD
• The University of South Dakota Sanford School of Medicine

• Associate Professor of ObGyn, Internal Medicine, and Neurosciences
• Avera McKennan Hospital & University Health Center

• Director of Female Pelvic Medicine & Reconstructive Surgery
• Avera Medical Group - Urogynecology
• Education:
• BS: Creighton University, Omaha, NE
• MD: The University of South Dakota Sanford School of Medicine
• ObGyn Residency: University of Wisconsin – Madison, WI
• FPMRS Fellowship: Good Samaritan Hospital Cincinnati, OH
• Board Certified
• Obstetrics and Gynecology
• Female Pelvic Medicine and Reconstructive Surgery

Disclosures

• Astellas
• AMAG
• Allergan

269

Objectives

• Develop strategies to assess and counsel women with
suspected bladder pain syndrome.

• Discuss treatment options for bladder pain syndrome.

• Develop a multidisciplinary team approach to manage the
symptoms associated with bladder pain syndrome.

Interstitial Cystitis (IC) / Bladder Pain
Syndrome (BPS)

• “An unpleasant sensation (pain, pressure, discomfort) perceived
to be related to the urinary bladder, associated with lower
urinary tract symptoms of more than 6 weeks duration in the
absence of infection or other identifiable causes.”

Hanno et al. J Urol 2011

Presentation • Best viewed as a continuum.

• Variable • Symptoms begin as mild and
• Pain intermittent and become more
• Urgency severe as the disease progresses.
• Frequency
• Nocturia • Pain becomes dominant symptom
• Dyspareunia with time and may impair physical,
• Recurrent urinary tract professional and personal life.

infections

270

Etiology

• Changes in Urothelial Permeability Associaterd syndromes:
• Increased Mast Cell Activity IBS
• Inflammatory Events Chronic Fatigue
• Neuro-immune Abnormalities Fibromyalgia

(Autoimmune disorder)
• Neuroplasticity of the Nervous

System
• Infectious Causes
• Generalized Somatic

Disorder/Central Sensitization of Pain

• Complex & Unknown

Hanno P et al. Neuro Urodynam 2010

Signs & Symptoms

•Numerous conditions have overlapping symptoms.

•Differential Diagnosis
•Carcinoma in situ
•Infection (UTI, STIs)
•Radiation changes
•Bladder stone
•Urethral diverticulum
•Overactive bladder
•Urethral syndrome
•Chronic pelvic pain
•Endometriosis
•Vulvar vestibulitis
•Vaginitis
•Irritable bowel syndrome
•Prolapse
•Genital cancers
•Pudendal nerve entrapment
•Levator ani muscle pain

French et al. Am Fam Physician 2011

www.AUAnet.org/guidelines

271

Counseling Patients

• Educate patients about normal bladder function, what is known and
not known about IC/BPS, benefits and risks of available treatments,
the fact no single treatment has been found effective for the majority
of patients and the fact that acceptable symptom control may require
trials of multiple therapeutic options before it is achieved.

• Manage the ups and downs.
• Empower the patient.
• Team approach.
• Develop coping skills.
• Goal of treatment is to improve quality of life and encourage realistic patient

expectations.

Hanno HM et al. J Urol 2011

Kindness is key.

Jerome Freeman, MD

UPOINT Philosophy of Phenotyping Pain

Nickel et al. J Urol 2009; Malde et al. BJU Int 2018

272

Cystoscopy

Glomerulations

Hunner’s Lesion

Glycosaminoglycan (GAG) Layer

Urologic Nursing, 2007; 27(1)

Controversies in Therapy

• Uncertainty about the mechanism for disease, different
therapies target different proposed factors.

• Lack of placebo controlled trials for therapeutic options.
• Inconsistent responses to therapy among patients, no single

treatment found to be universally effective.

273

Management of IC/BPS

• Early identification/detection and treatment to help prevent progression of
disease.

• Address:
1. Pain
2. Lower Urinary Tract Symptoms
3. Pain Beyond Bladder.

• Treat symptoms with a multimodal approach.
• Set realistic goals and expectations as individual responses vary and the

literature behind therapies are weak.
• Start with conservative therapy and involve patient in decision making.
• Consider simultaneous therapies if in the best interest of the patient.
• Ineffective treatments should be stopped.
• Reconsider diagnosis if not responding to therapy over adequate amount of time.

www.AUAnet.org/guidelines

First-Line Therapy

274

Behavioral Modifications

• Explain and educate the patient on the diagnosis, etiology and
management of IC/BPS.

• General Relaxation/Stress Management

• Psychology/Counseling

• Bladder retraining and appropriate fluid intake, educate on
normal bladder function.

• Pain management: when to refer to a pain clinic?
• Develop coping skills!

Dietary Modifications

• Often certain foods exacerbate symptoms

• Examples:Tomatoes, Mexican and Thai foods, pizza, spicy foods, coffee,
acidic juices, carbonated beverages, alcohol and chocolate

• Anti-inflammatory diet restricts:

• Alcohol, citrus, carbonated beverages, coffee, pineapple, berries, tea,
tomatoes, vinegar, cheeses, chocolate, aspartame and saccharin, onions,
pepper

• 64 oz of water should be drank daily

• Calcium glycerophosphate (Prelief) may be beneficial in prevention
of food related symptoms as is sodium bicarbonate (baking soda).

Bassaly et al. Female Pelvic Med Reconstruct Surg 2011

www.ic-network.com/diet

Shorter et al. J Urol 2007

275

Second-Line Therapy

Physical Therapy

• 85% of patients with IC/BPS have myofascial pain and high tone pelvic floor
dysfunction.

• Low risk modality with high success rates in IC/BPS.
• Myofascial physical therapy is not pelvic floor strengthening therapy, and that

such exercises (Kegels) may actually worsen symptoms.
• Consider other modalities used in conjunction with myofascial release therapy.

• Intravaginal medications: diazepam or baclofen
• Trigger point injections with analgesics and/or steroids
• Botox therapy to pelvic floor muscles

Gupta et al. Transl Androl Urol 2015

Oral Medications

• Pentosan polysulfate sodium (PPS)
• Repair epithelial dysfunction

• Hydroxyzine and Cimetidine
• Stabilize mast cells

• Tricyclic Antidepressants
• Modulate neural activity

• Others: gabapentin, antibiotics,
urinary anesthetics, muscle relaxants
and narcotics

Moldwin et al. J Urol 2007; Hanno P et al. Neuro Urodynam 2010

276

Marcu et al. Sem Reprod Med 2018

Intravesical Therapies

• Intravesical heparin • Clinicians often add lidocaine,
• Can be combined with sodium bicarbonate, steroids
alkalinized lidocaine. (triamcinolone), PPS, gentamicin,
and oxybutynin to “IC cocktails”.
• 50% dimethysulfoxide (DMSO):
FDA approved • Cochrane review: evidence limited.
• Lower concentrations available.
• My cocktail: Kenalog; 1%
• May teach patients to do lidocaine, Heparin, 0.9% sodium
themselves and allow for rescue chloride
therapy. Self Administration!

Dawson & Jamison Cochrane Database of Systematic Reviews 2007

Third-Line Therapy

277